Created by
Gary B. Rollman,
Emeritus Professor of Psychology,
University of Western Ontario
(In addition to links below, see weekly archives in the right column)

Monday, January 06, 2014

Pain-Topics News/Research UPDATES: Another Book About Pain; Only Much Better

Of nearly 240 million adults in the United States, more than 4 in 10, or about 100 million, live with chronic pain of some sort. Yet, the professional and popular news media focus more on abuses of pain medications than the dreaded conditions the drugs are intended to treat. Meanwhile, the suffering of untreated or mistreated patients with pain is largely overlooked.

In her new book — A Nation in Pain: Healing Our Biggest Health Problem — author Judy Foreman provides a deeply researched account of today's chronic pain crisis and reasons behind it, and she discusses some solutions that could be within reach. Far more than just a symptom, Foreman explains, chronic pain can be a disease in its own right, and the failure to manage pain better in the U.S. and other countries worldwide may be tantamount to torture.

A great many (perhaps, too many) books have been written on the subject of pain; all are well-intentioned and often they are self-published. While some of the books are of interest, most appear to be riddled with personal opinion, biased perspectives, and/or misinformation rather than being guided by facts and solid evidence. As a journalist and investigative health reporter, Foreman has done a noteworthy job of crafting easy-to-read text that also is excellently documented with enough citations of her evidentiary sources to satisfy even the most skeptical readers — which is quite rare for a book intended for both lay and professional audiences, as is A Nation in Pain.

The 464 page book, published by Oxford University Press, is ambitious in scope, covering in a mere 14 chapters subjects ranging from the nature of pain to genetic, age, gender, immune system, and mind-body influences. Foreman also examines various traditional, newly discovered, and alternative therapies for chronic pain.

She says that her research for A Nation in Pain spanned 5 years, during which time Foreman consulted a library of books and hundreds of scientific papers on pain. She also interviewed nearly 200 scientists and physicians, as well as countless patients, a few lawyers, and a handful of government officials. [Full disclosure: This writer was one of those persons consulted, and we can attest to the depth and relentless probing of her inquiries.]

A most appealing approach of the book is that it is simultaneously a textbook providing research insights and hard evidence, an investigative report replete with stories of affected patients and their families, and a personal memoir relating Foreman's own experiences with chronic pain and its treatment. Certainly, this juggling was no easy task, but the genre makes for fast-paced, informative reading while captivating even a casual reader.

Overall, Foreman suggests that there is an appalling mismatch between what people in pain need and what healthcare providers know about pain and its treatment — chronic pain in particular. She found that physicians in the U.S. typically receive only about 9 hours of education specifically on pain during 4 years of medical school — even veterinarians are better educated on pain management.

Systematic failure is equally evident at the federal government level; for example, in 2012 the U.S. National Institutes of Health spent only about 1% of its vast $30.8 billion budget on pain research, Foreman states, despite the fact that chronic pain was (and still is) a bigger problem than heart disease, cancer, and diabetes combined. At the same time, chronic pain in the U.S. conservatively costs as much as $650 billion per year in direct medical costs and lost productivity. Shamefully, there is no National Institute of Pain; yet, there are other Institutes addressing diverse health conditions that are important, but affect far fewer citizens and with less burden on the economy.

One of the more startling chapters in A Nation in Pain discusses the mismanagement of pain in pediatrics. Among other revelations, Foreman discloses how as recently as the mid-1980s in the U.S. healthcare professionals believed that young children, especially newborns and infants, seldom needed medication for pain relief and tolerated discomfort well. She recounts the particularly disturbing story of a newborn boy who was subjected to open-heart surgery without anesthesia — a practice that apparently was commonplace at the time, but somewhat of a dark secret known only among medical insiders. In general, management of pain in children of all ages has been deficient worldwide, as Foreman reveals in an examination of the research evidence.

Foreman devotes 2 chapters to the destructive "Opioid Wars," which have led to a misguided demonization of prescription opioid analgesics. Her discussion of this highly controversial topic is among the most fairly-balanced and evidence-based that we have seen. She observes that there are 2 separate public health "emergencies," sometimes called "epidemics": (a) undertreated pain influenced by some degree of limited access to opioids, and (b) the abuse of opioid analgesics for illegal or nonmedical purposes. She stresses, "whether the term 'epidemic' truly applies here is debatable."

Foreman recognizes that there are many sides to the ongoing debate and relatively little hard evidence one way or the other. As she states, "The complex truth is that opioids, especially opioids for long-term use in chronic non-cancer pain, are probably both under-prescribed for some patients and overprescribed for others." Opioids are not a solution for all patients or all types of severe pain, she acknowledges, and at best the pain relief they afford is only partial. She accordingly emphasizes:

"Opioids, in other words, may be necessary, but they are rarely sufficient. What I am saying is that government drug policy seems to be lopsided, politicized, stacked against legitimate pain patients, and fueled by public hysteria over abuse of prescription pain relievers. That hysteria, in turn, is fueled by often-misleading media coverage."

Those few sentences say a great deal about what has gone awry with concerns about opioid analgesics today. In support of those statements, Foreman laces her discussion with references to relevant research studies, while also distinguishing between good- versus poor-quality evidence — an objectively analytical perspective that is missing in most other books and articles on the subject.

As Foreman observes, the controversy over prescription analgesics is a "highly emotional struggle in which much of the 'debate' is driven not by scientific facts but by dueling anecdotes of horror." She aptly denounces a misguided popular press, prejudiced bureaucrats, and a small cadre of fear-mongering medical professionals for trying to foist a negatively slanted view of opioid pain relievers on the public as well as on the healthcare community at large. In balance, Foreman also tells how over-exuberant marketing by drug manufacturers has contributed to problematic analgesic prescribing and use.

Throughout the book various therapeutic approaches for managing chronic pain are discussed, including new developments still in preclinical or clinical trial stages. Additionally, a whole chapter is devoted to marijuana ("The Weed America Loves to Hate") and another focuses on exercise ("The Real Magic Bullet"). A range of CAM (Complementary & Alternative Medicine) therapies also are covered, with balanced discussions of pro and con research evidence for each.

Challenges of effective chronic-pain management are complex, with many obstacles to overcome on the path to finding practical solutions. As the diverse stories of patients with pain in the book demonstrate, pain often cannot be extinguished altogether; yet, it almost always can be better managed and patients can live more fulfilling lives. Foreman offers some suggestions for action — such as expanded pain education in medical schools, reforms of federal policies across the board, and increased funding for pain research — but it would require a separate book to do justice to such proposals. Meanwhile, for healthcare providers, researchers, policy makers, and patients and their loved ones, A Nation in Painis highly recommended reading.